SUMMARY. A
description is given of the nutritional therapy protocol used in the Palermo Burns Centre.
This protocol recommends the enteral approach, but also uses parenteral support in the
treatment of patients with burns in more than 25% body surface area. Enteral nutrition is
without any doubt an effective therapeutic approach which prevents complications, in
particular of the gastroenteric tract.

Introduction

Nutrition is a therapeutic technique
that can be compared to personalized infusion therapy and aimed antibiotic therapy. It is
used to complement the treatment of seriously burned and/or polytraumatized patients, many
of whom are also in a hypercatabolic state.
The choice of the type of nutrition, which is based on the patients' individual needs,
their physical characteristics, the type and duration of the burn disease, and the
presence of complications enables the physicians, on the basis of an accurate anamnesis
and careful monitoring, to adopt the best possible approach.
In seriously burned patients with important alterations of the hydroelectrolytic and
acid-base balances, the metabolic equilibrium is also affected. There is a tendency
towards hypercatabolism, especially if early nutrition is not initiated (after the first
48 hours) with the administration of nutritional substrates which within a few days
protect the digestive system, counteract infection and prevent malnutrition, by slowing
down hypercatabolism. These patients require a calorie increase varying between 50 and
120% of basic energy requirements. The catabolic state is manifested in a deficit of the
immunocompetent system and increased impairment of organ function, sometimes with fatal
consequences. 1,4,5,6,7

Methods

In the Palermo Burns Centre we
initiate our burn protocol 48 hours post-burn, preferring the enteral approach (Table
1), with the use of complete sernielemental polymer diets (in which the nutrients are
present in easily digestible form and in balanced proportions, and require only a part of
the digestive processes in order to be absorbed) with 1.5 kcal/ml, in addition to the
normal diet of about 1600 kcal, either in oral boluses or by continuous infusion by means
of a Nutripump and a nasogastric probe. In the first case we administer up to seven
boluses at 3-hour intervals between 6 a.m. and midnight, in amounts increasing from 350 to
1750 ml, with a maximum caloric input of 2625 kcal (Table II); in the second case
we infuse at varying rates between 30 and 125 ml/hr for 18 hours a day, with a maximum
input of 3375 kcal (Table III).
The comparative analysis of nutritional preparations indicates their protein, glucide and
lipid sources (Table IV). We would point out that monomer fonns (ditripeptides and
crystalline AA) are assimilated more than other protein forms but also that when the
intestine is intact there is no nutritional advantage in the use of monomer forms compared
to polymer forms (whole proteins or protein hydrolysates).
In very catabolic patients in whom the enteral input is insufficient we use supporting
parenteral nutritional therapy with 8.5% amino acids, 10-20% glucose and 10-20% lipids,
providing a total input of about 2000 kcal (parenteral nutrition/nitrogen caloric ratio
130/1), with 12.5 gm of nitrogen in 3000 ml volume in a peripheral vein.
In rare cases when the patient is unable to take nutrients orally or by nasogastric probe
we use parenteral nutritional therapy in a central vein, using 30% glucose, 8.5% amino
acids and 20% lipids. We thus provide an input varying between 2700 and 3500 kcal with
18.75 gm of nitrogen .
Nutritional therapy is generally administered to patients with deep extensive bums in more
than 25% BSA, especially if they present respiratory and/or septic complications.
The advantage of continuous monitoring, which at first sight may seem to be excessive, is
that in these unstable patients some parameters may vary considerably during the arc of
the day in relation to the phase of the bum: the samples are taken in sterile conditions
in unburned areas at a frequency ranging between every four hours and once a day (Table
V~. Body weight is very important and must be measured every time the patient is
changed, by means of self-regulating computerized scales."I'l

Advantages

Beneficial effect on structure of gastroenteric mucosa with
reduction of infection

In enteral nutritional therapy, if the
administration is carefully planned and properly managed, the typical septic complications
of parenteral nutritional therapy are absent, and side-effects, due mainly to the high
osmolarity of certain dietetic preparations, are minimal (Table V1). It must be
remembered that some drugs, including antiacids and H2 antagonists, can cause diarrhoea
and that reduced gastric acidity can favour bacterial colonization of the nasogastric
probe, causing gastroenteric disturbances and hyperthermia. These conditions are generally
attributed to the nutrients and are often responsible for the suspension of nutritional
therapy.

Protides

Glucids

Lipids

Lactose

Osmolite

88% casein
12% soya

maltodextrin
10% soya
50% MTC

40% maize

none

Ensure

88% casein
12% soya

79% maltodextrin
21% saccharose

maize oil

none

Nutrisond

casein

maltodextrin

veg. oils

0.4%

Nutrinaut

AA crystal.

maltodextrin
50% MTC

50%maize

none

Peptinaut
.

20% AA crystal
80% tri-tetrap

maltodextrin
50% MTC

50% maize

1%

Precision
N

lactoalbumin

maltodextrin
25% MTC

75% soya

none

Table
IV - Analysis of nutritional mixtures

Every 4 hours:

glycaemia

glycosuria

Twice a day:

gastric Ph

haerriatocrit

electrolytes

plasma osmolarity

acid base balance

haemoglobin

Once a day:

calcaemia

haemochrome

azotaernia

urea nitrogen

total diuresis

total protemaemia

alburninaerria

plasma creatinine

water balance

Every week:

bilimbinaernia

transaminasis

sideraemia

phosphoraernia

cholesterolaemia

triglycerides

urine test

Table
V - Monitoring

Cases of intolerance of the
diet administered have been very rare, usually being due to small quantities of lactose in
certain products rather than to mismanagement. These situations revert to normal with a
modification of the modality of administration or, more rarely. by a brief suspension of
administration or a change in the type of nutrient. Hyperglycaemia is easy to control,
thanks to the monitoring of glycaemia and glucosuria, with venous or subcutaneous infusion
of one unit for every 15 gm of glucose in normal conditions.

Check position of probe every 8 h
Check patency of probe every 4 h
Clean probe before and after administration
Cheek gastric residue every 2/4 h
Cheek quantity administered each time
Monitor gastric p11 in the event of pyrosis

Table
V1 - Enteral nutritional nursing with nasogastric probe

The complications during
peripheral parenteral nutrition are infrequent and not serious. They are mainly cases of
phlebitis that are easily resolved by changing the point of venous access or by increasing
local blood flow by means of nitroglycerine plasters in order to prevent chemical
phlebitis.
Complications arising during parenteral nutritional therapy involving a central vein are
more serious, though rare: haernatomas in the jugular or femoral cannulation site,
pneumothorax following subclavian cannulation, obstruction of the vein catheter due to
maladministration of drugs or to blood reflux, and dislodging of the catheter during
changing, bathing and wound dressing or because of psychomotor agitation in septic
patients.
Sepsis sometimes occurs in patients in whom it is necessary to create access points in
burned areas. In these cases hyperglycaemia is kept under control by careful monitoring
and by continuous infusion of insulin either directly in the dripfeed or by means of a
microinfusor at a rate of one unit per 5 gm.

Conclusions

Bum patients undergo a disruption of
one or more of the balances that are necessary for the physiological state of the
organism: this disruption is in part due to neuroendocrine and metabolic reactions to the
burn trauma that differ from the norm; nutritional needs are also considerably increased.
It is not always easy to identify the altered functions immediately and to support or
replace them artificially.
Enteral nutrition in the severely burned patient reduces the alterations caused by the
trauma. It also prevents toxic infective complications, particularly those originating in
the shock phase already in the first hours in the gastrointestinal tract, and improves the
absorption of nutrients, giving patients a higher level of comfort, thanks also to the
palatability of the diet. At the same time there is a direct therapeutic and systemic
action on the digestive system.